PREGNANCY HEALTH HISTORY QUESTIONNAIRE
Welcome to our office
All questions in this questionnaire are strictly confidential and will become part of your record.

Title:

Dr

Full Name:

Mr

Mrs

Ms

Miss

Todayâ&#x20AC;&#x2122;s date: __________________________

_________________________________ Preferred Name:____________________

Marital Status: Single

Partnered Married

Separated

Divorced

Widowed

Spouse / Partnerâ&#x20AC;&#x2122;s name: _________________________________________________________
Date of birth: _____________________ Number of children:_______ Ages:______________
Address:_______________________________________________________________________
Suburb:____________________________________________ Postcode:___________________
Home phone: ____________________________ Work phone: ___________________________
Mobile phone:___________________________ E mail address: _________________________
Occupation: _____________________________Employer:______________________________
Have you had chiropractic care before? Yes No
If yes, where did you go? _________________________________________________________
When was your last visit there? ____________________________________________________
Who may we thank for referring you to our clinic? ____________________________________

PERSONAL HEALTH HISTORY
How many weeks pregnant are you?__________ How many pregnancies have you had?_______
If this is a subsequent pregnancy and birth for you, how do you feel about your previous birth
experience/s?

Delighted

Neutral

Disheartened

Comment _____________________

___________________________________________________________________________________
Who are you receiving your prenatal care from?__________________________________________
What type of birth are you planning?

Hospital

Birthing centre

Home birth

What clinical tests have you had to date?________________________________________________

Any ultrasounds?____________________________________________________________________
Are you aware of the current position of your baby?______________________________________
Do you currently have any health issues? YES NO (If yes please explain)
___________________________________________________________________________________
___________________________________________________________________________________
If you are experiencing any complaints, please describe and mark on the diagram below:

Describe any trauma/accidents you have had: __________________________________________
Describe any surgeries you have had: _________________________________________________
List any medications/ supplements you take or have taken:________________________________
__________________________________________________________________________________
OTHER SYMPTOMS YOU HAVE OR HAVE HAD IN THE PAST (please circle)
Dizziness